HomeMy WebLinkAboutSeptic Pumping Slip - 49 CARLTON LANE 11/28/2017 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4 � �.4 � ��sw� �' �
DEP has provided this form for use�by focal Boards of Health. Other forms may be used, buff the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1, System Location: Left/Right front of house, Left/Right rear of house, Left,/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 6? /� t , { ,
Citylrown State Zip Code
2. System owner:
Name' l
Address(if different from location)
Citylrown ' State Code
p�
Telephone Numbers
' t
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. TypeW system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? F1 Yes U-M-0 If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6: System Pumped By:
Neff Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
y
_L S. Lowell waste Water
SignWHaule Date
t5formCdoc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping, Record
Form 4
DEP has provided this form'for use,by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facilit5f, Information
1. System Location: Left/Right front of house, Left kft rearofhour eft/right side of house, Left/
Right side of building, Left Right front of building, Left Right rear of building, Under deck
Address
L(
City/Town State Zip Code
2. System Owner:
Luc v,\x
Name'
Address(if different from location)
Cityfrown - State..) Zip Code
Telephone Number
B. Pumping Reco d
1. Date of Pumping 2. Quantity Pumped:
Date Go �s
3. Type of sySterw. El Cesspool(s) 0-Te—Ptic Tank El Tight Tank t.
0 Other(describe):
4. Effluent Tee Filter present? Ej Yap 0 If yes, was it cleaned? ❑ Yes F1 No
5. Condition of System:
A i
6.- System Pumped By.
Nell Bateson F5821
-Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
I
Sign (f Hauleru— Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record 1,
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. information
1. System Location: Left/Right front of house, Left/��r ar of o
ms4i, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address CA
Li
City/Town State Zip Code
2. System Owner. Uu 6-c c VA, r
Name'
Address(if different from location)
City/Town ' State CrZp Bode
Telephone Number —:
B. Pumping Record w
1. Date of Pumping � � —J
p g Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q Sep ict Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? F1 Y" D_ o If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of Sy temp` 7 �
t,
6; System Pumped By:
Neil.Bateson F6821
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf ere contents were disposed:
O.I,S: Lowell Waste Water
Sig4tufe qt Haule Date
t6form4.doc•46/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
x
r C ity/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other rm�rmay be used,°bc�fith
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left %Le6!-'7
rear of house;t;eft/right side of house, Left/
Right side of building, Left/Right front of building, Rigu❑rear ofbuilding, Under deck
Address 4 ff'�'.� o\ pE
CityrFown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityffown State Zip Code
Telephone Number
B. Pumping Record c� ,
1. Date of Pumpingt — 2. Quantity Pumped: 0
Date Gallons
Lh,F
3. Type of system: ❑ Cesspool(s) @/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�J/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
i
6. System Pumped By:
Neil Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G1,-S-Q0 Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of t
Commonwealth of Massachusetts
City/Town of
System Pumping Record
RECEIVED
Form 4
15 �Jfll
DEP has provided this form for use by local Boards of Health. Other for ,, a be;used, but the
information must be substantially the same as that provided here. Before u your
local Board of Health to determine the form they use. The System Pumpi A ed to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location": fUmiat-of house, right front of house, left side of house, right side of house, Left
rear of haus q, right r
ht rear of hWuse side of building, right rear of building, under deck.
Zit—yffown State Zip Code
2. System Owner: V\A
-------------
Name
Address�(if different-from location)
City/Town w State de
'-7
Telephone Number
B. Pumping Record
1. Date of Pumping Date ......................... 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [a-g-e-p-tic Tank 0 Tight Tank
F-1 Other(describe): ------------------
4. Effluent Tee Filter present? ❑ Yes � If yes, was it cleaned? n Yes El No
5. ConditiQn of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
-6-c;mp-an—y
7. Lo5%ion where contents were disposed:
G.L.S. Waste\(Ater/-\
Signature-of -,-ulej Date
t5form4.doc-06103 System Pumping Record-Page 1 of 1
IL
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
OF tw4w"
DEP has provided this form for use by local Boards of Health. Other forms p
information must be substantially the same as that provided here. Before Is form, check with your
local Board of Health t4 determine the form they use. The System Pumping Record must be submitted to
the local Board of Health OF other approving authority.
A. Facility Information
1. System Location: Left sde_.of.h.uIse,,Right side of house, Left front of house, Right front of house,
Left rear of hous Ri ht rea r of hot Left rear of building. Right rear of building.
Addressj /
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
—....-- - ----
City/Town State
6
Telephone Number
B. Pumping RecordS,
.
1. Date of Pumping _.. 2. Quantity Pumped: --- ---
Date Gallons
3. Type of system: ❑ Cesspool(s) -E Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes . "N'o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
elc�d V\'
6. System Pumped By:.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
--_.._ . .... ... . - _...__ w..._.—_
7. Locatini -ere contents were disposed:
L.S.DLow ste Water
__.. .....
Signature Ha er Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts _
City/Town of
_ System Pumping Record
_ Form 4
DEP has provided this form for use by local Boards of Health. Oth' 6 the
information must be substantially the same as that provided here: of'e t�si hrs r °oh° ck with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When tilling out 1. System Location: Left front, left rear, left side of house. Right fro6rig
ight side fbollfarms on the __.
computer,use
only the tab key Address
to move your.
cursor-do not
use the return Cityft own - State — — -- Zip Code
key. 2. System Owner:
OOL
_.__.__.
Name
Address(if different from location)
Cityrrown Stat�,R"'w ip_Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) [Jtic Tank [ Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned? Yes No
5. Condi i n of System:
6. System Pumped By:
Neil Bateson - F 5821 --
Name Vehicle License Number
Bateson Enterprises Inc —
Company
7. Lopatioft-wherp contents were disposed:
Au
.S.DLowell Waste Water
re of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 9 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Formti e4
4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1, Syst Location:
forms on the
computer, use TIC-7-1--k- --------
only the tab key Address
--
0�1
to move your
w.
cursor-do not State use the return Cftyrrovvn SZip Code
key. Z. System Owner:
Name
ren Address(if different from location)
CitylTown Stat ---'?-,------ZipCode
6 XI "",--
L-.
�,6 ( -___.-.-_._m--- _.
Telephone
-------------
telephone Number
B. Pumping Record
1. Date of Pumping -bate 2. Quantity Pumped: Gallons'
3. Type of system: F-1 Cesspool(s) E3- Septic Tank El Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? El Yes 9-`N�o If yes, was it cleaned? El Yes 0 No
5. Condition of System:
6. Syst PV mped By:
Name Vehicle License Number
3A.
.bom pan
7. Locatio her conte
p4 wert'l sposed:
Sign ur �auler Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
a
City/Town of 1
Sy
stem Pumping Record
Farm 4 2 5 2006
DEP has provided this form for use by local Boards-of Health. The SysteF4�Zi�ng`t~tec'¢rd must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When gt S#y l oc
forms on h
computer,use
only the tab key Address
to move your
cursor-do not
use the-return Cityrrown Sta e Zip Code
key. 2, System Owner:
Name
16A, Address(if different from location)
CitylTown Sta� _ .,. ,. 06de
Telephone Number
.B. Pumping Record
1. Date.of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) y eptic Tank ❑ Tight Tank
❑ Other(describe)` _ _._._w_...
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: "
6. System Pu �Bv�
Name b "_ Vehicle 6cense Number
Company
di sed:
A°
UGatlO ere ontents
. �°' .. ter, "'"4.�—""'a.�......r �,,,,✓
Signat re of au l Date
hftp://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM F '
PINGRECO"
DATE: ~
�i
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
ac
Lv�
DATE OF PUMPING: - QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PU1V PED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.® Lowell Waste
TOWN OF
SYSTEM PUMPING RECORD
DATE:�-_��
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
[4no- LvA
Cock (I a �bu5t--
DATE OF PUMPING: "j`j2S"Q a-L QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACILFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED awRL'D O:
Commonwealth of Mmachusel(s
Massachusetts
$y%tein Puipping Record
System Omier System Location
T
Date of Pumping: Qoafitity Pumped: gallons
Cesspool; No Yes Septic Tank: No Yes
System Pumped by: Fetredda License #
Contents transIbin-ed to Greater Lawrence Sariltary District
Date: Inspector'